Form D: TB Symptoms Health Screening Checklist
This section is to be completed by the student.
Please use ink and print clearly.
TB Proof of PPD
*To be completed by Student
Student ID # _________
COM:
DO
MS/MHS
Class of ________
COP:
GSOE:
PhD
MS/MHS-P
Name:______________________________ Gender: M
MSPAS/MPH:
F
MPH:
Date of Birth:___/___/___
Symptom sheet (page 1) due annually if (+) PPD exists for all programs
1.Have you ever had a positive PPD?
If yes , date ____________ & mm reading _____________
2. Have you ever been told you have active tuberculosis?
Yes
No
Yes
No
3. Have you ever taken INH or any other anti-TB drug?
Yes
No
If yes, list names:
4. Date and duration of medication regime
(months)
5. Have you ever had BCG Vaccination?
Yes
No
6. During the past year have you noticed:
 Unexplained weight loss? .....................................
Yes
No
 Decrease in your appetite?...................................
Yes
No
 Cough not associated with cold or flu? ...............
Yes
No
 Increase in AMOUNT of Sputum? ........................
Yes
No
 Change in COLOR of Sputum? ..............................
Yes
No
 Change in CONSISTENCY of Sputum? ................
Yes
No
 Blood Streaked Sputum? ......................................
Yes
No
 Night Sweats? ..............................................................
Yes
No
 Unexplained low grade fever? .............................
Yes
No
 Unusual tiredness or fatigue?.............................
Yes
No
 Swelling of lymph nodes?................................................
Yes
No
7. Have you had contact with a family member or partner who has been diagnosed with tuberculosis?
8.
Yes No
Have you or a member of your family been exposed to someone who is immune compromised?
Yes
No
Explain any: 'Yes" answers above
-------------------------------------------------------------------------------------------------------------------------------
Signature of Student
_
Date _____________________
Name__________________
Program/Year_____________
*To be completed by Health Care Provider 2 Step PPD
PPD Step #1
# 1Site L
R
Forearm
#1 Date Placed ___________
#1 Time Placed ____________
#1 Placed By (Name/Initials):____________
#1 Date Read:____________
#1 mm of Induration_______
#1 Read By (Name/Initials):____________
#1 Manufacturer_________________ Lot #. ________________ Exp. ___________
Orders:______________________________________________________________________________________________
____________________________________________________________________________________________________
Signature of Healthcare Provider ______________________
Date___/___/___
PPD Step #2
#2 1Site L
R
Forearm
#2 Date Placed ___________
#2 Time Placed ____________
#2 Placed By (Name/Initials):____________
#2 Date Read:____________
#2 mm of Induration_______
#2 Read By (Name/Initials):___________
#2 Manufacturer_________________ Lot #. ________________ Exp. ___________
Orders:______________________________________________________________________________________________
____________________________________________________________________________________________________
Signature of Healthcare Provider ______________________
Date___/___/___
 If a history of (+)PPD exists answer questions below.
Date of recent Chest X-Ray:__________ Results: (Check one) Positive for TB_____ Negative for TB_____
 COM: CXR requirement: Upon entering 1st and 3rd year
 PA & COP: CXR requirement : Annually
Quantiferon Gold serum test only applies if chest x-ray is positive.
Date:_______________
Results:__________________
No Further Action Needed _______ Chest X-Ray Requested_______ Further Evaluation Needed_____